Patient Feedback Form

As your laboratory and rural diagnostic imaging service provider, DSM wants your valuable input to help us further improve the quality of our patient-centered diagnostic services. Your suggestions, complaints and compliments help us to know where we can improve as well as what we’re doing right. We will respond to you as quickly as we can and within 3 business days of receipt.

Feedback Type*

Complaint

Compliment

Suggestion

DSM Site/Location*

DSM Service Type*

Lab (Blood/Urine Collection or testing)

Imaging (X-Ray, CT or Ultrasound)

Your Name*

FirstLast

Mailing Address*

Street AddressAddress Line 2CityProvincePostal Code

Email

Response

Call Back Requested

Comment Only( No Response Expected )

Daytime Phone*

Alternative Phone

May a message be left at your daytime telephone number?*

Yes

No

Are you representing someone else in this matter?

Yes

No

Your relationship to the patient

Family

Friend

N/A

Other

Patient's Name*

FirstLast

Date of experience*

Please, tell us what happened or what suggestions you have for improvement: